Modalities Update - Four Leg Rehab Inc · 2015-04-27 · !Over myositis ossificans !Over areas of reduced circulation !Over eyes !Over cervical ganglia or carotid sinus !To testes

Modalities Update

Copyright Laurie Edge-Hughes 1

  Ultrasound   Indications for the use of Ultrasound

§ Muscle spasm § Trigger points § Tendonitis § Soft tissue healing § Chronic synovitis § Adhesions § Calcification

§ Capsulitis § Bursitis § Contusions § Fracture healing § Joint Swelling § Wound healing § Warts

  Ultrasound   What does the literature say?   Is a highly utilized modality in human physical

therapy practice.

  Clinically, it has been shown to be of benefit for pain relief and improved function in osteoarthritis. (Srbely 2008; Rutjes et al 2010)

  Ultrasound   What does the literature say?   Dosages used in OA studies

  (Ozgonenel et al 2009)

  1 MHz frequency or 1 watt/cm2 power continuous ultrasound for 5 min

  (Tascioglu et al 2010)   CW U/S x 1Mhz x 2W/cm2 x 5 min/session x 5

days/week x 2 weeks

  Pulsed US x 1MHz x 2W/cm2 x 25% x 5 min/session x 5 days/week x 2 weeks

Modalities Update


  Ultrasound   What does the literature say?

  Dosages used in OA studies

  Cartilage effects   Activation of chondrocytes to increase collagen

synthesis   (Korstjens et al 2004 & 2008; Naito et al 2010)

  1.5MHz x 0.3W/cm2 x Pulsed x 20 min


  Dosages used in OA studies   (Huang & Yang et al 2005; Huang & Lin et al 2005)

  US improves strengthening benefits when combined with exercise in OA knees

  2.5W/cm2 x 25% Pulsed x 15 min x 24 sessions in 8 weeks

  Either CW x 1.5W/cm2 CW or 2.5W/cm2 x Pulsed 25% x 15min x 24 reps for 8 weeks. (NOTE: Pulsed was superior)


  Dosages used in Fracture Healing studies   (Santana-Rodriguez et al 2010; Shakouri et al 2010; Esteki

et al 2010; Korstjens et al 2004; Gebauer et al 2002)

  0.05W/cm x 3 min x 10+ days   1.5MHz x 0.03W/cm2 x pulsed x daily x 1 month

  1.5MHz x 0.03W/cm2 x pulsed x 20 min x 5days /week for ? weeks


  Dosages used on Myofascial Trigger Points   (Majlesi et al 2004)

  Conventional: 1.5W/cm2 x CW x 5 min x 10 – 15 sessions

  High Powered: CW & gradually increasing intensity, motionless – held to pain tolerance (4 – 5 sec), then ½ intensity for 15 sec, 3reps.

  Both groups improved, high power was better for pain relief faster

Modalities Update



  Dosages used on Myofascial Trigger Points   (Srbely et al 2007 & 2008)

  1MHz x CW x 1.0W/cm2 x 5 mins x area covered was twice the transducer head

  Significant improvement

  1MHz x 12% x 0.52W/cm2 x 10 min

  Significant differences at 1 – 3 mins post-RX but not at 10 – 15 mins.


  Dosages used on Pain   (Hsieh 2005; Mardiman et al 1995)

  1MHz x 50% x 1.0W/cm2 x 5 min

  1.1MHz x CW x 1.0W/cm2 x 5 min


  Dosages used on Calcification Lesions   (Rahman 2007; Ebenbichler et al 1999)

  1- 1.5 W/cm2 x 10 mins x 12 doses

  0.89MHz x 2.5W/cm2 x 25% x 15 min x 24 sessions

  Ultrasound   The wrench!

ú  Tendons, Ligament and capsules have 3X the absorption capability of muscle

ú  Is it even effective to Ultrasound for muscle lesions? (because of fascia)

ú  Is Pulsed ultrasound still okay?

Modalities Update


  Ultrasound   DOSAGES

ú  Ultrasound should be delivered for a minimum of 10 minutes (regardless of pulsed or continuous)   Houghton P, Nussbaum E, Hoens A, & Rennie S. Electrophysical Agents,

Physiotherapy Canada 62(5) Special Issue, 2010

  Ultrasound   New Research   Alexander LD et al. Exposure to low amounts of ultrasound energy does not

improve soft tissue shoulder pathology: a systematic review. Phys Ther, 90 (1), 2010: pp 14 – 25.

  Studies that show a benefit with ultrasound therapy for shoulder pathologies typically utilized 4x longer total exposure time and applied more U/S energy per session – as compared to studies that showed no benefit.

  New Research (brain twister!)   Houghton P. Ultrasound treatments involving 0.5 W/cm2, 20% duty cycle, for 5

minutes are not enough. Orthopaedic Division Review, September/October 2009, pp 35 – 36.

ú  W/cm2 x duty cycle (pulsing %) = spatial average temporal average (SATA).

ú  SATA x ultrasound head size (cm2) x Treatment Time (seconds) = Total Energy Exposure (Joules).

  Research papers that demonstrate efficacy in the use of ultrasound in soft tissue shoulder disorders deliver at least 2250 Joules per session and average exposure times over 4 weeks of 5 hours total. Hmmmm!

  New Research (brain twister!)   Houghton P. Ultrasound treatments involving 0.5 W/cm2, 20% duty cycle, for 5

minutes are not enough. Orthopaedic Division Review, September/October 2009, pp 35 – 36.

  So, if I treat a chronic biceps tendon at 1.0W/cm2, 100%, x 10 minutes (600sec)… I am only delivering 600 Joules.

  THEREFORE: I could choose to use 5cm sound head to deliver 1.0 W/cm2 continuous for 7.5 minutes to reach the desired dose!

  Or use a 1 cm sound head at 2.0 W/cm2 continuous for 18.75 minutes

Modalities Update


  Ultrasound   ANIMAL-SPECIFIC VARIABLES

 No pain  HAIR absorbs the ultrasound waves and can heat the hair and superficial skin  Pulsed setting?  Shave or clip the hair?  ‘Lots-o-goop’

  Continuous or Pulsed Ultrasound   Contraindications

§ Near a pregnant uterus § Over a malignancy § Over electronic devices § To actively bleeding tissues or persons with untreated hemorrhagic disorders § Regions with DVT or thrombophlebitis § Over recently irradiated tissues

§ Over myositis ossificans § Over areas of reduced circulation § Over eyes § Over cervical ganglia or carotid sinus § To testes § Over areas infected with tuberculosis

Houghton P, Nussbaum E, Hoens A. Electrophysical Agents, Physiotherapy Canada 62(5) Special Issue, 2010

  Continuous Ultrasound   Contraindications

§ ‘Persons’ with cognitive or communication impairments § Areas of impaired sensation § Areas of impaired circulation § Over areas affected by heat-sensitive skin

§ To infected tissues under tension (i.e. abscess) § Inflamed tissues (from recent injury or exacerbation of chronic inflammatory condition) § To areas overlying cemented or plastic implants


  Pulsed or Continuous Ultrasound   Can be used with caution

ú  Be cautious of your settings (lower intensity, & more frequent monitoring)

§ Spinal cord or superficial peripheral nerves § Regenerating nerves § Active epiphysis § “at risk” or fragile skin


Modalities Update


  Pulsed Ultrasound   Can be used with caution

ú  Be cautious of your settings (lower intensity, & more frequent monitoring)

§ Over cemented or plastic implants § To areas of impaired sensation § To areas of impaired circulation § Over heat sensitive skin § To infected tissues with open drainage § To areas with regenerating nerves § ‘Persons’ with cognitive or communication impairments § Inflamed tissues (a/a)


  Pulsed or Continuous Ultrasound   SAFE

§ Over metal implants (with intact overlying skin) § The head § The chest wall (providing the rib case is intact) § Persons with cardiac failure or hypertension

§ Areas near or over Chronic wounds

  Pulsed Ultrasound   SAFE


  Ultrasound   PHONOPHORESIS

ú Lidex Gel = Fluocinonide 0.05%

ú Betamethasone

ú Synalar Gel, Flurocinolone, Acetonide

ú Cortisone does not work

•  Electrical Stimulation •  TENS •  Microcurrent

Modalities Update


  Electrical Muscle Stimulation   The use of electrical current to

stimulate a muscle contraction in the underlying muscle tissue

  Electrical Muscle Stimulation   INDICATIONS

§ Improper muscle firing sequences § Joint effusion § Muscle disuse atrophy § Circulatory disorders § Tendon / Fracture healing

§ Neurological atrophy § Pain § Protective muscle spasm § Post injury / disease muscle inhibition § Dermal ulcers

  Electrical Muscle Stimulation   CONTRAINDICATIONS

§ Near electrical devices § To the low back / abdomen in pregnant women § To acupuncture points on pregnant women § Anywhere on a pregnant woman

§ To regions of known or suspected malignancy § To areas of active DVT / thrombophlebitis § To actively bleeding tissues or persons with untreated hemorrhagic disorders

Modalities Update


  Electrical Muscle Stimulation   CONTRAINDICATIONS

§ To infected tissues, tuberculosis, or wounds with underlying osteomyelitis § To the chest n patients with cardiac disease, arrhythmias, or heart failure § To the neck or head region of patients known to have seizures

§ Transcranially w/o specialized training § To areas near reproductive organs or genitalia w/o specialized training § To areas near /over eyes § To the anterior neck / over the carotid sinus § To open areas of skin

  Electrical Muscle Stimulation

§ Areas of impaired circulation § The area unstable d/t recent surgery, bone fracture, or osteoporosis § The crest or the intercostal muscles § The lower abdomen § To recently radiated tissues

§ (e.g. clinicians may treat these with caution – lower intensities and/or more monitoring)

§ Active epiphysis § Over skin conditions (e.g. eczema, psoriasis) § Over areas with impaired sensation § Patients with cognitive / communication problems

CONTRAINDICATIONS PRECAUTIONS

  Electrical Muscle Stimulation

§ Over intact skin overlying metal, plastic, or cement implants § Over inflamed tissues (d/t recent injury or exacerbation of a chronic inflammatory condition)

SAFE   Electrical Muscle Stimulation

  PARAMETERS

ú  Frequency: (Hertz, Pulses per second, Pulse rate)

  For tetanic muscle contraction used for strengthening 30 – 60 Hz is usually recommended. (I use 5Hz!)   20Hz has been shown to prevent atrophy of slow-twitch muscle fibers

  30 Hz has been shown to prevent atrophy of fast-twitch muscle fibers

  2Hz & 10Hz are best for remediation of disuse atrophy

Dupont Salter et al 2003; Boonyarom et al 2009

Modalities Update


  ELECTRICAL MUSCLE STIMULATION   Dosages in studies

ú  (Sinacore et al 1990) ú  Type II fibres are most affected with chronic

diseases. ú  EMS at 50 Hz, 50 reps total, 5 sec on, 2 sec off, 2

second rise, was a viable treatment for disuse atrophy

  Electrical Muscle Stimulation   PARAMETERS

ú Phase / Pulse Duration: (Selections of 100, 200 or 300 microseconds)  Humans report than 100 usec is more comfortable. 800 usec will recruit small pain fibers

  Electrical Muscle Stimulation   PARAMETERS

ú Waveform: who cares! There are no good studies to prove the value of one over the other.

ú ON / Off Times: Duty cycle: suggested is 1:2 or up to 1:5.   I use 1:1 or continuous if the animal is not working with the EMS

  I use 1:2 if weight shifting while using the EMS

  Electrical Muscle Stimulation   ELECTRODE PLACEMENT

ú Motor Points:  Usually mid belly where a nerve fiber ends

 The black electrode is the best one to place over the motor point and the red electrode distal or at opposite end.

 Clinically, just get two electrode over the same muscle = good enough!!!

  SHAVE or ‘Spot Goop’?

Modalities Update


  Electrical Muscle Stimulation   UTILIZATION

ú Co-contractions

ú  Post-op in first 4 weeks ú  Passive modality in animals

 Early on ú Active – Assisted  Later on

ú Warm up needed???

  Electrical Muscle Stimulation   USE IN Lower Motor Neuron Lesions

  Neuropraxia: (temporary bruising and inflammation or damage to the nerve) ú  You can stimulate below the lesion to get a muscle twitch

  Axonotmesis: (damage to the axon with severance or blockage, but neural sheath is still intact. Nerve may grow together) ú  Grows at 1mm per day or 1 inch a month for up to 2 yrs ú  You are unable to stimulate a muscle twitch below the lesion

  Neurotmesis: (severance or crushing completely) ú  The nerve will die unless surgically reattached and even then

the individual nerve fibers must reconnect   Pulse Widths of 300 usec might be better at recruiting more

muscle fibers and actually get a twitch from a denervated muscle

  Electrical Muscle Stimulation   IONTOPHORESIS: The use of an electrical

current to drive a medication transdermally into the underlying tissue.

  Know the polarity of the compound and under which electrode to put it ú  Principle: that like charged ions repel each other…

( ie. Put a positively charged solution under the Red / Positive / Anode.)

  TENS : Transcutaneous Electrical Neuromuscular Stimulation   An electrical current (much like EMS, but

utilizing higher or lower frequencies) for pain relief.

  Analgesic Mechanisms ú Descending inhibitory pathways

ú  Pain Gating at the spinal cord level ú  Release of endogenous opiates

Modalities Update


  TENS   SETTINGS

ú  For Acute Pain: 60 – 200 Hz and lower pulse widths produce a fast acting pain relief. The relief is short lasting however

ú  For Chronic Pain: 2 – 4 Hz with a higher pulse width produces longer lasting pain relief.

  Transcutaneous Electrical Nerve Stimulation   HIGH-frequency TENS ú  Selectively stimulates larger diameter peripheral

nerve fibres which in turn helps to ‘block’ nociceptive activity in smaller afferents at segmental levels.

ú  endorphins in the bloodstream & CSF, and

enkephalins in the CSF ú  release of the excitatory neurotransmitters

glutamate and substance P in the spinal cord dorsal horn in animals with inflammation

  Transcutaneous Electrical Nerve Stimulation   LOW-Frequency TENS (acupuncture-like

TENS) 1.  Stimulates a release of endogenous opiates

2.  Activates opioid, GABA, serotonin, and muscarinic receptors to reduce dorsal horn neuron activity & nociception

3.  It has also been shown that peripheral opioid receptors are also responsible for low-frequency (but not high-frequency) TENS analgesia.

  TENS   CONTRAINDICATIONS

ú  As per Electrical Muscle Stimulation

  CAUTIONS ú  Anterior chest wall or lower abdomen ú  Areas of impaired circulation

  SAFE ú  Over areas unstable due to recent surgery, bone

fracture, or osteoporosis

ú  Areas around or within chronic wounds of known etiology or open wounds with localized infection

Modalities Update


  TENS   APPLICATION

ú Application of electrode placement is a mix of art and science. Knowledge of the neuromuscular anatomy is helpful.

  Incorporate acupuncture points

 Localized areas of pain  Over a nerve

 Over a nerve root (that supplies a dermatome / myotome in the painful area)

Canine Nerves, Nerve Roots, and Muscle Innervation Nerves Root Muscles

Radial Nerve C7 – T2 All extensor muscles of the elbow & carpus & digits, supinator, brachioradialis, APL, EPL

Median Nerve C8 – T2 Pron. Teres, Pron Quad., FCR, SDF, Radial head of DDF Ulnar Nerve C8 – T2 FCU, Ulnar & Humeral heads of DDF, Lumbricals, Interossei & elbow

jt Musculocutaneus Nerve C7 (C8) Coracobrachilis, biceps, brachialis Axillary Nerve C7, (C6 & C8) Teres major, teres minor, deltoid (and subscapularis) Subscapular Nerve C6 – C7 Subscapularis Suprascapular Nerve C6, (C7) Supraspinatus & infraspinatus Pectoral Nerve C7, C8 Superficial & deep pectorals Thoracodorsal Nerve C8, (C7, T1) Latissimus dorsi Femoral Nerve L4 – L6, (L3) All of the Quadriceps complex, iliopsoas, Sartorius Sciatic Nerve Tibial Peroneal Supf & Deep

L6, L7, (S1, S2) Hamstrings, quadratus femoris, gemelli, obturator internus, gastrocs, popliteus, tibialis posterior, tibialis anterior, digital flexotrs and extensors, Fibularis brevis, EHL, muscles of the foot

Obturator Nerve L5, L6 Obturator externus, pectineus, adductor, gracilis Anterior Gluteal Nerve L7, S1 Glutei, TFL, capsularis Posterior Gluteal Nerve S1 – S3 Biceps femoris, Middle & Superficial glutes

  Microcurrent Electrical Stimulation (MES) (MENS) (MET)   Electrical current at very low levels –

often at below perceivable levels ú Current less than 1 mA / 1000μA

Modalities Update


  Microcurrent

 Shown to be beneficial for: ú Resistant trigger points over head, neck, &

face

ú TMJ disorders

ú Epicondylitis & shoulder peritendinitis

ú Low back disorders

ú Wounds / Ulcers

ú Neuropathic pain / Post-operative pain

  Microcurrent   In the literature:

ú  Reduction in DOMS (applied immed post-Ex) – Curtis et al 2010

ú  Improved function after TKR at 3 mo mark following immed post-op MENS Rx x 10 apps – Rockstroh et al 2010

ú MET 0.5Hz x 1000muA x 20 mins/d x 7 days= better than TENS & helps with bruxism pain - Rajpurohit et al 2010

  Microcurrent   In the literature: (Rexing et al 2010)

ú  Cold compress, MET with bandage, or cold compress with bandage = effective in reducing swelling 72 hours post CCLR in dogs vs bandage alone.

ú  MET – Alpha Stim 600uA used a) crossing the joint in a large X, crossing in a small X and crossing both rear limbs. 0.5Hz (50% duty cycle, bipolar asymmetrical rectangular wave).

ú  Using 2 probes (2 pairs with small X, 3 pairs with large X, and 3 pairs) 30 – 45 sec per pair with a total time of 5 – 7 minutes.

  Microcurrent   In the literature: (Tan et al 2006)

ú  Cranial Electrical Stimulation (CES = Microcurrent delivered via earclips to affect the brain) resulted in significant decrease in pain intensity in pts with SCI

ú  100uA - 500uA x 1 hr/day x 21 days (Alpha-Stim)

Modalities Update


•  LASER •  & LEDS

  LASER: Light Amplification by Stimulated Emission of Radiation   The use of light energy to affect underlying

tissues.

  PHYSICS

 A photon directed at an atom causes an absorption of energy. This excites the atom molecule, causing electrons to jump from inner orbit to outer orbits. Then when the atom falls back again it gives off energy again.

  LASER   Attributes of LASER

ú  Coherence (same wavelength) ú  Monochromicity (color of light – wavelength) ú  Collimating (parallel beams / no divergence) ú  600nm – 1000nm is the therapeutic window ú  Tissues and cells absorb different wave length

  Skin = red   Bone = green   Cell Membrane = infrared

ú  Attenuation (loss of power) occurs more in darker skins or areas of more superficial circulation

ú  Absorption is hindered in older more dehydrated skin

Modalities Update


  LASER   Effects of LASER

§ Cartilage stimulation § Fibroblastic production § Endorphin release (pain reduction) § Increased angiogenesis § Decrease micro-organisms (lymphocyte production) § Enhances immune cells

§ Healing of leg ulcers § Accelerated inflammation phase § Acceleration of collagen synthesis § Reduce oxidative stress § Inhibition of transmission at the neuromuscular jct

  LASER   INDICATIONS

§ Arthritic Conditions § Bursitis, Fasciitis, Capsulitis § Neuralgia, Nerve/SpC lesions § Ligament / Tendon injuries § Wounds § Contractures / Scars § Fracture healing

§ To increase circulation § Pain § Muscle Spasm & DOMS § Hematomas § Superficial skin lesions (including warts, eczema, psoriasis) § Use on Acupuncture points & Myofacial TrPs

  LASER   CONTRAINDICATIONS

§ Tissues infected with tuberculosis or other virulent bacteria § The low back or abdomen in pregnant patients § Regions known or suspected of malignancy

§ Regions with active DVT / thrombophlebitis § Over eyes § Over reproductive organs § Actively bleeding tissue or patients with untreated haemorrhagic disorders


  LASER   CAUTIONS   (Clinicians may elect to treat with caution (lower

intensities &/or closer monitoring)

§ Recently irradiated tissues § Patients with photosensitivity disorders § Persons with infections with a compromised immune function

§ Patients with cognitive or communication impairments § Active epiphysis § Anterior neck & carotid sinus


Modalities Update


  LASER   SAFE

§ Tissues infected with non-virulent bacteria § Areas of impaired circulation § Areas of impaired sensation § Areas overlying regenerating nerves § Areas of damages, ‘at risk’ skin, skin diseases, chronic wounds

§ Patients with hypertension or cardiac failure § Areas overlying electronic devices § Over implants composed of metal, plastic, or cement § Inflamed tissues d/t recent injury or flare of chronic inflammatory conditions § Over active epiphysis

  LASER   Classification of Lasers

Class 1 (<0.5 mW) § Visible & Non-visible § No eye or skin danger § Some pointers, car entry and remotes § No heating & No healing

Class 2 (< 1mW) § Visible § Safe for short periods of time on eyes and for extended periods of time on the skin

Class 3 (1mW – 500mW) 3A <5mW and 3B >5mW lasers § Visible & Invisible § Hazardous to eye but not much to skin (<1 degree C.) § Helium Neon (HeNe) § Infra-red § Galium Arsenide (GaAs) § Galium Aluminum Arsenide

Class 4 (> 500mW) § 4a( NEW ‘cold’ lasers) / 4b (surgical) § Increases tissue temp § Surgical = Dehydration of tissue and coagulation of protein § Thermolysis § Evaporation § CO2 / Argon / YAG laser § Fire Hazard

  LASER   PENETRATION

ú 0.5 – 1cm direct OR up to 5cm

ú 1 – 1.5 cm indirect OR up to 10cm

ú  (depends on wavelength of the light)

  LASER   ENERGY

ú  Measurement of power over time   Energy (Joules) = Watts (W) x Seconds  1 Joule = 1 Watt X 1 Second

ú  Lasers come in mW of power:1000mW=1W  To get 1J. Of energy from a 5mW laser, you would need 200 seconds of timer per point

 To get the same effect from a 50mW laser, you would use 20 seconds of time

 To get the same effect from a 200mW laser, you would need 5 seconds of time

 And with a 500mW laser, it takes 2 seconds

Modalities Update


  LASER   Traditional DOSAGE

ú  For Acute Injuries: 0.05 – 2 Joules/cm2

ú  For Subacute Injuries: 3 – 4 Joules/cm2 ú  For Chronic Injuries: 5 – 8 Joules/cm2

ú  For Bio-inhibition: 9 – 12 Joules/cm2

ú  *** AT the TARGET TISSUE ***

ú  Dosage time may need to be increased get the desired joules at a deeper target tissue

  THERAPEUTIC LASER ›  General effectiveness for PAIN RELIEF due to:

  Anti-inflammatory mechanisms similar to pharmacological agents (celecoxib, meloxicam, diclofenac, & dexamethasone)

  Ability to reduce oxidative stress

  Improved angiogenesis   Augmentation of collagen synthesis & skeletal repair

  Inhibition of transmition at the neuromuscular junction (reduced nerve firing)

Bjordal et al 2006; Chow et al 2009

  THERAPEUTIC LASER   NEW brilliant, high quality reviews & meta-

analyses! (Tumilty et al 2010)   TENDINOPATHY lesions:

ú  Epicondylitis: positive studies used wavelength of 904nm x3.5J/cm2 and 1064nm x 150J/cm2

ú  Rotator Cuff: 4.3 – 42J/cm2 using 904 or 820nm lasers

ú  Achilles tendinopathy: 1.8 – 3.6J/cm2 x 904 or 820nm lasers

ú  DeQuervains: 4J/cm2 x 830nm laser.

  THERAPEUTIC LASER   NEW brilliant, high quality reviews & meta-

analyses! (Chow et al 2009)   Acute and chronic NECK PAIN:

ú  Optimum dose per point for an 820-830nm laser was 5.9 Joules and

ú  Using a 904nm super-pulsed laser, it was 2.2 Joules.

ú  Number of reps and Rx / week were variable.

ú  Positive effects were immediate and could be maintained for up to 3 months after treatment ended!

Modalities Update


  THERAPEUTIC LASER   NEW-ish brilliant, high quality reviews &

meta-analyses! (Bjordal et al 2006)   LLLT at high doses (7.5 J/cm2) at the target

tissue in the first 72 hours (to reduce inflammation)

  Followed by the lower doses (2 J/cm2) at target tissues in subsequent days (to promote tissue repair)

  THERAPEUTIC LASER   Recent-‘ish’ brilliant, high quality reviews &

meta-analyses! (Bjordal et al 2003)   Low level laser therapy significantly reduces

pain and improves health status in chronic joint disorders ú  Knee doses: 2.1 – 12 Joules (total per session) ú  Lumbar spine doses: 16 – 60 Joules (per session)

ú  TMJ doses: 0.7 – 2.1 Joules (per session)

ú  Cervical spine: 10 – 60 Joules (per session)

  THERAPEUTIC LASER   Nerves (Shamir... 2001; Rochkind... 2007; Rochkind... 2007; Rochkind... 2007)

ú  Rat sciatic nerve, 780nm x 30min x 21 days, to SpC segments corresponding to nerve and to injured nerve.

ú  LLLT to SpC segments corresponding to the crushed sciatic N. 16mW x 632nm He-Ne laser x 30 mins x 21 days

ú  Laser: 780 nm x 250 mW x 3hrs x 21 days to the injured peripheral nerve & 2 h to the corresponding SPc segments

ú  Laser: 200 mW x 780-nm x 14 days to the corresponding SpC segments (15 min) & reconstructed nerve (15 min)

  THERAPEUTIC LASER   Spinal Cord (Byrnes...2005; Wu... 2009; Rochkind...2002)

ú  Laser: 810nm x150mW x 1589 J/cm2 daily (administering LLLT for 2997 seconds/day) x 14 days)

ú  Laser: 780nm x 250mW x 30 min/day x 14 days

Modalities Update


  LASER - dosage ú Depth of Penetration   Irradiation Time [secs] = ((D x A) / P) x (1 + d)  D = Desired Dose at Target Tissue [Joules/cm2]  A = Area of Target Tissue [sq cm]  P = Power of Incident Beam (Watts)  d = Depth of Target Tissue (cm)

 Note: the parameter 'd' is limited to a range of 0-4cm, with values 1-4 only applicable to the deeper-penetrating wavelengths (approx. 760-860nm GaAlAs and super-pulsed 904nm GaAs).

  So.....

  LASER - dosage

ú Depth of Penetration   So, If I treat a chronic 2 cm2 tendon lesion 2

cm deep, with the goal to deliver 8 J/cm2, with my 500mW laser, then I would laser for 96 seconds per point ú  (the equivalent of 48 J/cm2 at the surface!!).

Note: Based on a 1cm2 lesion Courtesy of SpectraVet

  LASER   Techniques

ú  Points should be spaced 1cm2 apart when covering a large expanse

ú  For open lesions, treat with the probe being 1cm away or less. Clear plastic food wrap over the lesion will avoid direct contact as well.

Modalities Update


  LASER   Techniques

ú  Some laser machines allow for the selection of Hertz. Follow the manufacturers guidelines when selecting dosage & settings. (No studies) (Most research is done with continuous wave)

ú Machines should be calibrated regularly ú  (Protective eye goggles should be used by

the practitioner and animal owner. The dog’s eyes should be shielded.)

  LED: Light Emitting Diodes ú Not quite LASERS  Monochromatic

 Brilliant

 Non-coherent

 Usually cheaper

ú May allow for treatment of a broader range of tissue types and photochemical reactions  Various Visible and Invisible light

•  Pulsed Electromagnetic Field

Modalities Update


  Magnetic Field Therapy   To create a magnetic field a current must

flow through a conductor such as wire.

  When current flows through a wire a magnetic field is induced at right angles to the wire.

  Magnetic Field Therapy   Theoretic Mechanism of Action

ú  Damaged / Diseased cells have altered rest potentials (permeability to Na+ and K+). The rest potential of the cell is proportional to the ion exchange occurring at the cell membrane.

ú  Ions are affected by the rhythm of the pulsation when introduced to a PEMF

ú  Ion exchange is responsible for O2 utilization of the cell

ú  Lack of O2 utilization is a problem with delayed healing and arthritic joints

  Pulsed Electromagnetic Field Therapy   EFFECTS OF PEMF

ú  Enhanced cartilage repair

 Stimulation of chondrocytes ú  Increase in collagen synthesis

ú  Increase in osteogenesis

  Pulsed Electromagnetic Field Therapy   INDICATIONS

§ Bone Healing § Inflammation § Muscle Spasm § Pain § Disorders of the Neuro system § Rheumatology § Coronary / Circulatory diseases § Post-Operative

§ Degenerative diseases of the musculoskeletal system § Infection § Poor circulation § MS § Parkinsons § Post-trauma § Burns & Wounds § Tendon healing

Modalities Update


  Pulsed Electromagnetic Field Therapy   CONTRAINDICATIONS

ú Hemorrhage ú  Electrical implants

ú Cancer

  Pulsed Electromagnetic Field Therapy   PARAMETERS

ú Magnetic field is measured in Gauss (G) or Tesla (T)

ú  PEMF have a maximum power of 100 G and utilize DC current. (This is far less than external field powers that can have a negative biological effect such as cell phone, power lines, transformers, appliances and medical devices which utilize AC)

ú  Static Magnets are at least 500G

  PEMF   PARAMETERS

ú  Frequency Cycle (Hertz)  0.5 Hz may cause vasoconstriction

 18 Hz may cause vasodilation

ú Centurion PEMF setting  2Hz (acute)

 15Hz (subacute)  30Hz (chronic)


ú CARTILAGE ú  In the Literature: (Fini…2005; Zorzi…2007)

ú  PEMF x 3 months x 6hr/day x 75Hz x 1.6mT = increased cartilage thickness

ú  PEMF x 75Hz x 1.5 mT x 90 days x 6 hours / day = reduced NSAID use & increased knee Fx/pain scores

Modalities Update



ú  BONE ú  In the Literature: (Ibiwoye… 2004; Matsumoto…2000)

ú  PEMF 15Hz x 3hrs/day x 7 days a week x 10 weeks = reduced osteotomy gap size

ú  PEMF 100Hz, pulse width of 25usec (x lower Teslas) = increased bone contact ratios & bone area ratios


ú  Tendons ú  In the Literature: (Strauch…2006; Robotti…1999; Lee…1997)

ú  PEMF 30 mins/day x 27.12Mhz = 69% increase in tensile strength of repaired tendons in rat Achilles)

ú  15Hz, peak amplitude 12mW x 8 hours daily = decrease in tensile strength and an increase in peritendinous adhesion (chick tendons).

ú  17Hz x 15-min sessions x 5.1mT = increased physiological alignment of collagen fibres in Achilles of rats


ú  In the Literature: (Walker…1994; Crowe…2003)

ú NERVE ú  PEMF: 2 Hz x 0.3 mT x 4 h/day during Days 1-5 post-

injury = Increase in functional recover (assess day 43)

ú  SPINAL CORD ú  PMF may help with motor function recovery and

lesions volume size after acute SpC Injury (applied x 12 weeks mid-thoracic spine – cats)

  Maybe you learned something from all of this…

  Or maybe you got your laundry done with me yammering in the background!

  Either way… good on ya! See you at the course!

Cheers! Laurie

Modalities Update


  Thermal Therapies (HOT)   Mechanisms of Heat Exchange

ú Conduction (direct contact) ie hot packs

ú Convection (directing air or liquid) ie dryers

ú Radiation (from warm to cool) ie lamps

ú Conversion (altering energy) ie Ultrasound

ú Evaporation (fluid changes to vapor) ie perspiration

  Thermal Therapies (HOT)   INDICATIONS

 Pain Relief  To increase circulation

 Muscle spasm  Facilitate tissue healing  Prepare a stiff joint or muscle for exercise

 Chronic swelling

 Tissue scarring

  Thermal Therapies (HOT)

  CONTRAINDICATIONS

•  Large area or high enough temps as to raise core body temps in pregnant patients, or patients with cardiac issues •  Patients with DVT / thrombosis / thrombophlebitis •  Patients infected with TB •  Areas of impaired sensation •  Actively bleeding tissues •  Over reproductive organs (testes)

•  Recently irradiated tissues •  In patients unable to give accurate / timely feedback •  Areas of impaired circulation •  Inflamed tissues (d/t recent injury or chronic flare-up) •  Over heat sensitive skin •  Over areas of skin break-down •  Areas of edema


  CAUTIONS

•  Areas near or over eyes •  Anterior neck & carotid sinus •  Pregnant women •  People with cardiac failure

Modalities Update



  SAFE

•  Over implants containing metal, plastic, or cement •  Over electronic devices •  Near chronic wounds •  Over superficial or regenerating nerves

•  Near the head, chest, or heart •  Over active epiphysis •  To patients with hypertension

  Thermal Therapies (HOT)   PHYSIOLOGICAL EFFECTS

 Increased local circulation  Decreased pain  Increased tissue extensibility  Decreased muscle spasm  Muscle relaxation

ú Via dilation of blood vessels and stimulation of local circulation, heat helps to mobilize tissue & metabolites, increase tissue oxygenation and increase metabolic rate of cells and enzyme systems.

  THERMOTHERAPY ›  Proposed sequences of physiological &

cellular functions... (Belanger 2004)

  Thermal Therapies (HOT)   APPLICATION

ú  Best AFTER the acute inflammation stage ú  Superficial heat directly penetrates only 1cm ú  Most profound physiological effects are when

tissue temps are raised to 105 - 113 degrees F. ú  Skin & subQ fat will rise to these temps after 5

mins of superficial heat ú  Deeper tissues need 15 – 30 mins to achieve the

same (with superficial heat) ú  Water as hot as the hand can tolerate is 101 – 105

F. ú  Heat in one location may cause reflex vasodilation

at a distal site.

Modalities Update


  Cryotherapy (COLD)   INDICATIONS

ú  Pain relief ú  Inflammation

ú  Reduce swelling ú Hemorrhage ú  Fever

ú Muscle guarding spasm ú Control bleeding

  Cryotherapy (COLD)   Contraindications

Impaired circulation Over chronic wounds Over regenerating nerves Patients with cold sensitivities

To patients with DVT / thrombosis / thrombophlepitis To anterior neck & carotid sinus To tissues affected with tuberculosis

  Cryotherapy (COLD)   PRECAUTIONS (may treat this condition

with lower intensities and/or more monitoring) ú To areas of impaired sensation

ú Tissues near / over eyes

ú Damaged or at risk skin

ú To patients with cardiac failure (reduce intensity or size of application)

ú To patients with hypertension (reduce intensity or size of application)

  Cryotherapy (COLD)   SAFE

ú  Over active epiphysis

ú  Over metal, plastic, or cement implants

ú  Over electronic devices ú  Over areas of known malignancy

ú  Over low back or abdomen of pregnant patients

ú  Over recently irradiated tissues ú  Over reproductive organs

ú  Skin diseased areas

ú  Over the chest, heart, head ú  Any inflamed tissues

Modalities Update


  Cryotherapy (COLD)   EFFECTS

ú Decrease in local circulation ú Decrease in pain ú Decrease in tissue extensibility

  MECHANISMS OF ACTION

 Constriction of blood vessels  Decreased tissue metabolism   (inhibits inflamm. mediators)

 Affects small myelinated nerve fibres   (reduce nerved conduction)

 Cold can directly affect 1 – 4 cm depths

  CRYOTHERAPY   Physiologic effects... (Sluka 2009; Belanger 2004)

  Cryotherapy (COLD)   APPLICATION

ú  Apply in the first 48 hrs following acute musculoskeletal injuries or any time there is heat and swelling

ú  Application is generally for 10 – 20 minutes with a re-warming period of twice the time of the ice application = 1:2 ratio on/off time.

ú  Effects occur when tissue temp gets between 59 – 66 degrees F.

ú Do not allow for an airspace between the skin and cold medium (air gets colder and can damage the skin)

  Time to Play!!

Documents

Modalities Update - Four Leg Rehab Inc · 2015-04-27 · !Over myositis ossificans !Over areas of reduced circulation !Over eyes !Over cervical ganglia or carotid sinus !To testes